Substandard and falsified medical product recalls in Zambia from 2018 to 2021 and implications on the quality surveillance systems

Background

Substandard and falsified (SF) medical products are removed from circulation through a process called 'product recall' by medicines regulatory agencies. In Zambia, the Zambia Medicines Regulatory Authority (ZAMRA) is responsible for recalling SF medical products from the Zambian market through passive and active surveillance methods. This study aimed to describe the prevalence of recalls of SF medical products and to analyse the frequently recalled therapeutic categories, dosage forms, categories of defects that led to the recalls and their sources with respect to the country of the marketing authorisation holder (MAH) or manufacturer.

Methods

We conducted a descriptive cross-sectional review of the product recalls issued by ZAMRA between January 2018 and December 2021. A search for all medical product alerts and recalls issued by ZAMRA was carried out by reviewing the internal post-marketing surveillance database kept at ZAMRA headquarters. Data were extracted using a structured Excel database and analysed using Microsoft Excel.

Results

A total of 119 alerts were received during the review period, of which 83 (69.7%) were product recalls. Oral solid dosage forms were the most recalled dosage form (53%). Furthermore, the number of recalls increased in 2020 (44.6%) and 2021 (22.9%), with the majority (20.5%) of the recalled products being substandard products classified as antiseptics and disinfectants and were attributed to the high demand during the COVID-19 pandemic. Manufacturing laboratory control issues were the reason for product recall in almost half (47.4%) of the cases. Most of the products recalled originated from India (38.6%), followed by Zambia (25.3%). Only one suspected falsified product was recalled between 2018 and 2021. A total of 66 recalls of the 83 products were initiated by ZAMRA, with only 17 voluntarily by foreign MAHs. No product recall was initiated by the local representatives of foreign manufacturers or MAH.

Conclusion

The majority of the pharmaceutical product recalls in Zambia were substandard products. Manufacturing laboratory control issues lead to most recalls and require investigation of the root causes, preventive action, and strict compliance with the good manufacturing practices guidelines by manufacturers.

Knowledge and practices toward COVID-19 among healthcare students: A cross-sectional study at the University of Zambia

Background

The COVID-19 pandemic led to the disruption of physical classes for university students globally, as large gatherings fuelled the transmission of the virus. In the efforts to mitigate its transmission and return to normality, prevention measures, including vaccination, have been encouraged. Therefore, it is critical to understand the knowledge and practices of students regarding COVID-19. This study assessed the knowledge and practices toward COVID-19 among healthcare students at the University of Zambia.

Materials and methods

This questionnaire-based cross-sectional study was carried out from August 2021 to October 2021 among 478 healthcare students (pharmacy, physiotherapy, nursing, biomedical, medicine, and radiography). We used a previously validated questionnaire to measure knowledge and practice. The predictors of knowledge and practices were assessed using logistic regression with robust estimation of standard errors. Statistical analysis was conducted using Stata/BE version 17.0.

Results

Of the 478 respondents, 243 (50.8%) were females. A larger proportion, 175 (36.6%) were in Pharmacy training, and 156 (32.6%) were in their fifth year of study. The overall mean knowledge score of the participants was 87.9 (SD = 16.1), being higher at 89.6 (SD = 14.3) among medical students and the lowest at 86.7 (SD = 17.1) among Pharmacy students, although this was statistically non-significant (p = 0.488). The overall mean practice score was 60.0 (SD = 24.7), being significantly higher at 63.5 (23.4) among nursing, physiotherapy and environmental students compared to other students (p = 0.048). In multivariable analysis, the participant training program was non-significantly associated with knowledge and practice toward COVID-19. However, increased age (AOR = 1.09, 95% CI: 1.01-1.117) and residing in urban areas (AOR = 1.79, 95% CI: 1.07-3.01) than in rural areas were associated with higher odds of good practice toward COVID-19.

Conclusion

The healthcare students generally showed good knowledge levels and poor practices toward COVID-19. Further, there was no evidence of a difference in knowledge of COVID-19 among healthcare students. These findings suggest the need for implementation strategies to be centered on improving the practices of students toward COVID-19.

Knowledge, attitudes and practices on antimicrobial resistance among pharmacy personnel and nurses at a tertiary hospital in Ndola, Zambia: implications for antimicrobial stewardship programmes

Introduction

Antimicrobial resistance (AMR) is a global public health problem that has led to increased morbidity and mortality, especially in low- and middle-income countries such as Zambia. This study evaluated AMR knowledge, attitudes and practices among pharmacy personnel and nurses at Ndola Teaching Hospital, Zambia's second-largest hospital.

Methods

A descriptive cross-sectional study was conducted among 263 participants using a structured questionnaire. Data analysis was performed with IBM SPSS version 23.0. All statistical tests were conducted at a 95% confidence level. Univariate analysis was used to determine differences in knowledge, attitudes and practices on AMR between pharmacy personnel and nurses.

Results

Of the 263 participants, 225 (85.6%) were nurses and 38 (14.4%) were pharmacy personnel. Compared with nurses, pharmacy personnel had better knowledge of the spread of resistant bacteria from one person to another (P = 0.001) and the use of antibiotics in livestock as a contributing factor to AMR (P = 0.01). Pharmacy personnel had better attitudes towards AMR as a public health problem (P = 0.001) and the use of antibiotics in livestock as a source of resistant pathogens (P = 001). Lastly, more pharmacy personnel than nurses participated in awareness campaigns (P = 0.029), continued professional development (P = 0.001) and courses on the use of antibiotics and AMR (P = 0.028).

Conclusions

The study showed that most participants had adequate knowledge, a positive attitude and good practices towards AMR. Significant differences in knowledge, attitudes and practices were observed between pharmacy personnel and nurses in AMR, highlighting a need for increased educational programmes for these healthcare personnel.

Prevalence and factors associated with COVID-19 vaccine acceptance in Zambia: a web-based cross-sectional study

Introduction

vaccinations against COVID-19 have been instituted to contain the pandemic. However, information about the acceptability of COVID-19 vaccines in Zambia is lacking. Therefore, the study assessed the prevalence and factors associated with COVID-19 vaccine acceptance among the general population in Zambia.

Methods

this was an online questionnaire-based cross-sectional study conducted from 13^th April to 21^st May 2021. We included adult Zambians who had access to Facebook and WhatsApp. A multivariable logistic regression model was fitted to determine factors influencing vaccine acceptability. Data were analysed using Stata version 16.1.

Results

of the 677 participants, only 33.4% (n = 226) would accept the vaccine if made available to them. In multivariable regression analysis, respondents who were older than 41 years compared to the 18 to 23 years age group (aOR: 2.77, 95% CI: 1.03-7.48), those who agreed (aOR; 22.85, 95% CI: 11.49-45.49) or did not know (aOR; 3.73, 95% CI: 2.29-6.07) compared to those who disagreed that the COVID-19 vaccine passed through all the necessary stages to ensure its safety and effectiveness, and those who were aware (aOR; 11.13, 95% CI: 5.31-23.35) compared to those who were not aware that the COVID-19 vaccine reduces virus transmission, were more likely to accept the vaccine. Conversely, entrepreneurs compared to government employees (aOR; 0.24, 95% CI: 0.07-0.79) were less likely to accept vaccination.

Conclusion

awareness of the COVID-19 vaccine was high despite low acceptability levels. These findings are significant as they highlight the need to develop strategies for improving vaccine acceptability in Zambia.

Assessment of knowledge, attitude and practices on antibiotic resistance among undergraduate medical students in the school of medicine at the University of Zambia

Background: The issue of antibiotic resistance has become a global public health concern, with an extensive clinical and economic burden. The study aimed to assess the knowledge, attitude, and practices of antibiotic resistance among undergraduate medical students at the University of Zambia.Methods: This cross-sectional study was conducted at the University of Zambia Ridgeway Campus. A structured questionnaire was administered to 260 randomly selected undergraduate medical students. Data were analyzed using Statistical Package for Social Sciences (SPSS) version 22.0. Associations between dependent and independent variables were done using a Chi-square test. The statistical significance was done at 95% confidence level (p<0.05). Ethical approval was done by the University of Zambia Health Sciences Research Ethics Committee.Results: The study found that 227 of 260 (87.3%) of the medical students had good knowledge on antibiotic use and resistance. The majority of the medical students 252 of 260 (96.9%) had positive attitudes and 195 of 260 (75%) had good practices towards antibiotic resistance. There was a significant difference between the year of study and the level of knowledge (χ2=16.333, p=0.003). There was no significant difference between the year of study and the attitude of the participants (χ2=4.061, p=0.398). A significant difference was found between the year of study and the practices of the respondents (χ2=10.926, p=0.027).Conclusions: The medical students had good knowledge, a positive attitude, and good practices towards antibiotic resistance. Final year students had higher levels of knowledge and attitude but lower levels of practice compared to other years of study.

Determinants of high residual post-PCV13 pneumococcal vaccine-type carriage in Blantyre, Malawi: a modelling study

BACKGROUND

In November 2011, Malawi introduced the 13-valent pneumococcal conjugate vaccine (PCV13) into the routine infant schedule. Four to 7 years after introduction (2015-2018), rolling prospective nasopharyngeal carriage surveys were performed in the city of Blantyre. Carriage of Streptococcus pneumoniae vaccine serotypes (VT) remained higher than reported in high-income countries, and impact was asymmetric across age groups.

METHODS

A dynamic transmission model was fit to survey data using a Bayesian Markov-chain Monte Carlo approach, to obtain insights into the determinants of post-PCV13 age-specific VT carriage.

RESULTS

Accumulation of naturally acquired immunity with age and age-specific transmission potential were both key to reproducing the observed data. VT carriage reduction peaked sequentially over time, earlier in younger and later in older age groups. Estimated vaccine efficacy (protection against carriage) was 66.87% (95% CI 50.49-82.26%), similar to previous estimates. Ten-year projected vaccine impact (VT carriage reduction) among 0-9 years old was lower than observed in other settings, at 76.23% (CI 95% 68.02-81.96%), with sensitivity analyses demonstrating this to be mainly driven by a high local force of infection.

CONCLUSIONS

There are both vaccine-related and host-related determinants of post-PCV13 pneumococcal VT transmission in Blantyre with vaccine impact determined by an age-specific, local force of infection. These findings are likely to be generalisable to other Sub-Saharan African countries in which PCV impact on carriage (and therefore herd protection) has been lower than desired, and have implications for the interpretation of post-PCV carriage studies and future vaccination programs.

Antihyperglycemic and Antihyperlipidemic Effects of Aqueous Extracts of Lannea edulis in Alloxan-Induced Diabetic Rats

Lannea edulis (Sond.) Engl. commonly known as wild grape is used traditionally for the treatment of diabetes. It is only found in Eastern and Southern Africa. Phytochemical screening, antihyperglycemic and antihyperlipidemic effects of aqueous extracts of L. edulis in alloxan induced diabetic rats were carried out. We report herein the findings of this research work. Lannea edulis crude aqueous extracts were obtained by hot infusion and evaporation method. Phytochemical screening was carried out and subsequently toxicity studies of the aqueous extracts were performed to establish the Lethal Dose 50 (LD50) in albino rats. Alloxan monohydrate was used to induce diabetes in the rats. Lannea edulis positive control group doses of 100, 300, and 500 mg/kg were administered to 3 groups for 14 days. The positive control group was administered 5 mg/kg of glibenclamide. The negative and normal control groups were administered distilled water. To determine fasting blood glucose, blood was drawn on days 0, 1, 3, 5, 7, and 14 while it was drawn on days 0 and 14 for the determination of lipids. Phytochemical screening revealed the presence of flavonoids, saponins, tannins, cardiac glycosides, alkaloids and steroids. L. edulis diabetic positive control groups showed significant (P < 0.05) dose dependent reductions in fasting blood glucose levels. When day 0 mean blood glucose levels were compared to day 3 mean blood glucose levels of their respective groups, the 300 mg/kg L. edulis group showed a 23.3% drop and the 500 mg/kg L. edulis group showed a 52.6% drop. The 100 mg/kg L. edulis diabetic positive control group showed a 25.1% drop by day 5, the day on which it showed statistical significance (P < 0.05) compared to the diabetic control. In addition, administration of aqueous extracts of L. edulis to diabetic rats for 14 days significantly decreased (P < 0.05) the levels of serum total cholesterol, triglycerides, Low Density Lipoprotein (LDL) and Very Low Density Lipoprotein (VLDL) whilst increasing the levels of High Density Lipoprotein (HDL), when compared to the diabetic control group. It was concluded that L. edulis showed significant and dose dependent antihyperglycemic and antihyperlipidemic effects thus confirming its traditional use.

The quality and diagnostic value of open narratives in verbal autopsy: a mixed-methods analysis of partnered interviews from Malawi

BACKGROUND

Verbal autopsy (VA), the process of interviewing a deceased's family or caregiver about signs and symptoms leading up to death, employs tools that ask a series of closed questions and can include an open narrative where respondents give an unprompted account of events preceding death. The extent to which an individual interviewer, who generally does not interpret the data, affects the quality of this data, and therefore the assigned cause of death, is poorly documented. We aimed to examine inter-interviewer reliability of open narrative and closed question data gathered during VA interviews.

METHODS

During the introduction of VA data collection, as part of a larger study in Mchinji district, Malawi, we conducted partner interviews whereby two interviewers independently recorded open narrative and closed questions during the same interview. Closed questions were collected using a smartphone application (mobile-InterVA) and open narratives using pen and paper. We used mixed methods of analysis to evaluate the differences between recorded responses to open narratives and closed questions, causes of death assigned, and additional information gathered by open narrative.

RESULTS

Eighteen partner interviews were conducted, with complete data for 11 pairs. Comparing closed questions between interviewers, the median number of differences was 1 (IQR: 0.5-3.5) of an average 65 answered; mean inter-interviewer concordance was 92% (IQR: 92-99%). Discrepancies in open narratives were summarized in five categories: demographics, history and care-seeking, diagnoses and symptoms, treatment and cultural. Most discrepancies were seen in the reporting of diagnoses and symptoms (e.g., malaria diagnosis); only one pair demonstrated no clear differences. The average number of clinical symptoms reported was 9 in open narratives and 20 in the closed questions. Open narratives contained additional information on health seeking and social issues surrounding deaths, which closed questions did not gather.

CONCLUSIONS

The information gleaned during open narratives was subject to inter-interviewer variability and contained a limited number of symptom indicators, suggesting that their use for assigning cause of death is questionable. However, they contained rich information on care-seeking, healthcare provision and social factors in the lead-up to death, which may be a valuable source of information for promoting accountable health services.

Avian malaria in New Zealand

Avian malaria parasites of the genus Plasmodium have the ability to cause morbidity and mortality in naïve hosts, and their impact on the native biodiversity is potentially serious. Over the last decade, avian malaria has aroused increasing interest as an emerging disease in New Zealand with some endemic avian species, such as the endangered mohua (Mohua ochrocephala), thought to be particularly susceptible. To date, avian malaria parasites have been found in 35 different bird species in New Zealand and have been diagnosed as causing death in threatened species such as dotterel (Charadrius obscurus), South Island saddleback (Philesturnus carunculatus carunculatus), mohua, hihi (Notiomystis cincta) and two species of kiwi (Apteryx spp.). Introduced blackbirds (Turdus merula) have been found to be carriers of at least three strains of Plasmodium spp. and because they are very commonly infected, they are likely sources of infection for many of New Zealand's endemic birds. The spread and abundance of introduced and endemic mosquitoes as the result of climate change is also likely to be an important factor in the high prevalence of infection in some regions and at certain times of the year. Although still limited, there is a growing understanding of the ecology and epidemiology of Plasmodium spp. in New Zealand. Molecular biology has played an important part in this process and has markedly improved our understanding of the taxonomy of the genus Plasmodium. This review presents our current state of knowledge, discusses the possible infection and disease outcomes, the implications for host behaviour and reproduction, methods of diagnosis of infection, and the possible vectors for transmission of the disease in New Zealand.

Accuracy and costs of rapid human immunodeficiency virus testing technologies in rural hospitals in Zambia

OBJECTIVE

To evaluate the accuracy and costs of newer rapid human immunodeficiency virus (HIV) antibody tests in primary health care settings in rural Zambia.

METHODS

Three rural hospitals participated in this study. During a baseline assessment period, HIV testing practices were recorded on 250 consecutive clients at each hospital. Baseline evaluation was compared with 250 subsequent consecutive clients tested using a testing algorithm consisting of an initial screening HIV Dipstick test (McDonald Scientific [PVT] Limited, Harare, Zimbabwe) followed by confirmatory testing of all reactive specimens using the HIV Capillus test (Cambridge Diagnostics, Galway, Ireland), in conformity with World Health Organization HIV testing recommendations. Quality control was performed at a national university teaching hospital laboratory.

RESULTS

A total of 1,500 clients was entered, with an HIV seropositivity rate of 53.2%. Most HIV testing was performed on patients with signs and symptoms suggestive of HIV infection. Same-day results were provided for only 16%. The HIV Dipstick testing algorithm sensitivity was 96.9%, and specificity was 98.0%. Counselor dissatisfaction was greater with the Dipstick algorithm as a result of 5.3% discordant results. Use of the HIV Dipstick testing algorithm cost between US $3.00 and US $3.80 per client tested.

CONCLUSIONS

The accuracy of HIV testing in unsophisticated rural laboratories in Zambia is acceptable. Although HIV Dipstick testing algorithm costs were relatively high for a developing country, this HIV testing procedure is currently the most economical method available in Zambia. Accurate, less costly HIV testing algorithms are still needed.

Hyperthermic enhancement of cell killing by mitomycin C in mitomycin C-resistant Chinese hamster ovary cells

The interaction of hyperthermia and mitomycin C (MMC) was studied in wild-type Chinese hamster ovary cells and in Chinese hamster ovary cells selected for resistance to MMC. Hyperthermic potentiation of MMC activity was maximal if heating was done simultaneously, or up to 3 h following MMC exposure. Heat enhanced the effect of MMC in both drug-sensitive and -resistant cells. Dose enhancement ratios increased from 1.3-2.0 at 42 degrees C to 2.6-3.8 at 43.5 degrees C and were similar for all cell lines. Cellular uptake of MMC was determined by high pressure liquid chromatography. MMC uptake was similar in the drug-sensitive and -resistant cell lines at 37 degrees C. Hyperthermia (43.5 degrees C) increased cellular uptake of MMC by 78 and 27% in MMC-sensitive and -resistant cell lines. MMC-resistant cells were more sensitive to heat alone at 42, 43, and 44 degrees C. The results suggest that tumor cells that have developed resistance to MMC might be treated effectively with MMC combined with heat to augment the response to MMC. Resistance to MMC may also render tumor cells more sensitive to hyperthermia.